Social worker knew teen was planning suicide day she died says coroner

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Tyra Williams-Dorey told her social worker the day she was going to die by suicide.

March 2, 2015.

Then she followed through.

“Some time ago she told her social worker that she would kill herself March 2nd. She had set other deadlines in the past,” wrote Dr. Robert Berckmans, in his coroner’s death investigation report dated Oct. 16, 2015 that was provided to APTN News Tuesday.

The 17-year-old also sketched what she intended to do on a piece of paper with the date circled on a calendar for the month of March while at the Lynwood Charlton Centre, an a residential treatment institution in Hamilton, Ont. specializing in mental health.

“We had many conversations about that date,” said her father, Nygel Dorey.

Williams-Dorey left school early that day and walked into a wooded area where she hanged herself.

“They told me they were on high alert, but they let her go to school alone. Then she left school alone,” said Dorey, of Lynwood and the social worker.

“It’s not like I could show up that day and walk her to school. I didn’t have the authority.”

APTN put questions to Lynwood’s executive director about the day Williams-Dorey died and what his staff knew about her plans.

Alex Thomson said her death impacted everyone, but didn’t respond directly to the questions.

“While she was in our service, Lynwood Charlton Centre collaboratively developed a comprehensive plan of care for Tyra between the organizations involved in her care,” wrote Thomson in an email Tuesday. “The plan addressed areas of concern as identified by Tyra and others. As she progressed, the plan included a graduated return to her normal routine over time, and required continuous  communication and confirmation of the plan amongst the service partners.”

Dorey said “everyone” had known for “at least a couple months” about the date. She had previously attempted suicide by overdosing on her antidepressant medications in November 2014.

“She (had) set two dates before,” said Dorey.

Lynwood is the same institution where Devon Freeman, 16, died by suicide in October 2017. He was found over six months later no more than 35 metres behind Lynwood’s building in a wooded area.

The First Nations teen had been reported “missing” when he didn’t return to Lynwood.

No inquest was called into either of the suicides, but Freeman’s family requested one Dec. 5. The coroner’s office has yet to decide. It has 60 days from when the request is made.

APTN first reported Williams-Dorey’s death Jan. 6 connecting it to Lynwood.

Freeman’s family believed then the second, similar, suicide added additional support for an inquest.

This new information just increased the need according to their lawyer.

“This raises serious questions around what steps staff take, or don’t take, when they have information relating to the suicidal tendencies of children in care,” said Justin Safayeni, lawyer for Pamela Freeman, Devon’s grandmother.

“Calling an inquest will hopefully help us find some answers and prevent this from happening to another child.”

APTN also reported Williams-Dorey’s death was part of a special coroner’s report into 11 other deaths involving children that died in foster or group homes between Jan. 1, 2014 to July 31, 2017. Eight of the children were First Nations.

The coroner organized the panel of child welfare experts and their work was restricted to reviewing each victim’s child welfare file. They could not question any person, agency or home. Still they found the system had failed the kids over and over.

There’s a section for “Tyra” that details how she came into care, as she was struggling with several matters, including sexual abuse she suffered as a child that APTN confirmed was a friend of her mother’s. She had been splitting time between her father’s place and mother’s before being taken into state-sanctioned custody through what’s known as a temporary care agreement with the Catholic Children’s Aid Society in Hamilton.

Within two years, and several serious attempts on her life involving hospitalization, she was gone.

Despite all of this Williams-Dorey was straight-A student and captain of her basketball team according to the coroner.

“She cared about people. She would do what she could to help people. She had a big heart,” Dorey previously told APTN about his daughter.

Dorey agreed to tell his daughter’s story hoping it would help the Freeman’s get an inquest that he believes should include his daughter.

He said the panel report just didn’t do enough to provide answers. Several families share that concern.

The panel’s report wrote Williams-Dorey was “surrounded by a group of helping professionals from the Society, school and children’s mental health sector who maintained extremely close contact with her and communicated with one another on a very regular basis regarding her welfare.”

Yet, the day she died she was alone.

The coroner said Williams-Dorey left school at 1 p.m. and didn’t return. She last spoke to her social worker the day before.

Later that day the social worker was there helping to find her.

“The social worker found a suicide note in her locker. Using cellphone tower triangulation she was found by police around (8:30 p.m.) hanging from a tree on the escarpment,” wrote Berckmans.

Williams-Dorey arrived at hospital at 9:20 p.m.

“She was in asystole,” wrote the coroner, meaning the most serious form of cardiac arrest.

She had no heartbeat

Doctors tried to warm her body but she remained in asystole until pronounced dead at 4:20 a.m. Mar. 3, 2015.

The coroner reported she had multiple cuts over her body from self-harming.

APTN asked Dorey if he ever received his daughter’s suicide note, or goodbye letter.

“No,” he said.

But he wants it.

The coroner’s report also wasn’t provided either until APTN advised Dorey on how to obtain it.

It was sent by Dr. Karen Schiff, the regional supervising coroner in Hamilton.

It’s Schiff who’s deciding whether to call an inquest.